REPUBLIC OF CAMEROON
PEACE WORK FATHERLAND
NATIONAL INSTITUTE OF STATISTICS

IDENTIFICATION:

LOCALITY NAME: ___
NAME OF HEAD OF HOUSEHOLD: ___
REGION: ___
CLUSTER NUMBER: ___
STRUCTURE NUMBER: ___
HOUSEHOLD NUMBER: ___

URBAN/RURAL:

RESIDENCE:

HOUSEHOLD SELECTED FOR MEN'S SURVEY AND HIV TEST?

INTERVIEWER VISITS:

INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___
RESULTS___

NEXT VISIT [FOR INTERVIEWERS 1 AND 2]
DATE__
TIME__

FINAL VISIT
DAY__
MONTH__
YEAR 19__
INTERVIEWER__
RESULT__

TOTAL NUMBER OF VISITS____

QUESTIONNAIRE LANGUAGE:

INTERVIEW LANGUAGE:

INTERPRETER?

TOTAL IN HOUSEHOLD: ___
TOTAL NUMBER OF ELIGIBLE WOMEN: ___
TOTAL NUMBER OF ELIGIBLE MEN: ___
LINE NUMBER OF RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE: ___

FIELD EDITED BY:

NAME: ___
DATE ___

SUPERVISOR:

NAME: ___
DATE ___

OFFICE EDITED BY:
NAME: ___

KEYED BY:
NAME: ___

INFORMED CONSENT

Hello. My name is ___and I am working with the National Institute of Statistics. We are conducting, in collaboration with the Ministry of Health, a national of various health problems. We would very much appreciate your participation in this survey. The survey usually takes between 20 and 25 minutes to complete.

In this study, we would first like to ask you some questions about your household. All information you provide will be kept strictly confidential and will not be shared with anyone outside of the investigation team. Participation in this survey is completely voluntary. If I happened to ask a question you do not want to answer, let me know and I'll move on to the next question, or you can stop the interview at any time. However, we hope that you will participate in this survey since your opinion is very important.

At this time, do you want to ask me anything about the survey?

May I begin the interview now?

INTERVIEWER SIGNATURE: ___
DATE: ___

HOUSEHOLD TABLE

Now we would like some information on the people usually living in your household or who currently live with you.

1) LINE NUMBER:

2) USUAL RESIDENTS AND VISITORS:
Please give the name of those persons usually living in your household or who spent last night here, starting with the head of household.

AFTER HAVING LISTED THE NAMES OF THE MEMBERS OF THE HOUSEHOLD AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.

THEN ASK THE APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON.

3) AFFILIATION WITH THE HEAD OF HOUSEHOLD:
What is the familial relation between (NAME) and the head of household?

4) SEX: Is (NAME) male or female?

5) RESIDENCE: Does (NAME) normally live here?

6) RESIDENCE: Did (NAME) sleep here last night?

7) AGE: How old is (NAME)?

8) MARITAL STATUS: What is the marital status of (NAME)?

9) ELIGIBILITY: CIRCLE THE LINE NUMBER OF WOMEN BETWEEN AGES 15-49.

10) ELIGIBILITY: CHECK THE COVER PAGE. IF HOUSEHOLD SELECTED FOR THE MEN'S SURVEY, 1 (YES), CIRCLE THE LINE NUMBER OF MEN BETWEEN AGES 15-59 IF MEN'S SURVEY IS PLANNED.

11) CHECK THE COVER PAGE. IF HOUSEHOLD SELECTED FOR THE MEN'S SURVEY, 2 (NO), CIRCLE THE LINE NUMBER OF ALL CHILDREN BETWEEN 0-5 YEARS OLD.

2A. Just to be sure I have a complete listing, are there any other person such as small children or infants that we have not listed?

2B. Are there any other people who may not be members of your family, such as domestic servants, employees, tenants or friends who usually live here?

2C. Do you have guests or temporary visitors or others who slept here last night and were not listed?

13) PARENTAL SURVIVORSHIP: Is his or her mother still living?

14) Does the biological mother live in this household or did she visit last night?

IF YES : What is her name ?

WRITE LINE NUMBER OF MOTHER.

IF NOT, WRITE '00'.

16) Is his or her father still living?

17) ALIVE : Does the biological father live in this household or did he visit last night?

IF YES : What is his name?

WRITE LINE NUMBER OF FATHER.

IF NOT, WRITE '00'.

23) IF 3 YEARS OLD OR OLDER: Did (NAME) attend school? Or kindergarten?

24) What is the highest level of education (NAME) completed ?
What is the last class that he or she successfully completed?

LEVEL:

CLASS:

25) IF BETWEEN AGES OF 3 AND 24: CURRENT OR RECENT SCHOOL ATTENDANCE: Did (NAME) attend school or kindergarten at any time during the 2010-2011 school year?

26) During this current school year, what level and class was (NAME) in?

LEVEL:

CLASS:

27) Did (NAME) attend school or kindergarten at any time during the last school year (2009-2010)?

28) During this school year, what level and class was (NAME) in ?

LEVEL:

CLASS:

32) IF BETWEEN 0 AND 4 YEARS OLD: BIRTH DECLARATION: Does (NAME) have birth certificate?

IF NO, PROBE: Was (NAME)'s birth declared to the state?

***CODES FOR QUESTIONS 24, 26, AND 28: EDUCATION LEVEL

DECEASED PERSONS

33) Now I would like to ask you some more questions about your household. Think about the past 12 months. Did a member of your household die during the past 12 months?

34) How many members of your household died during the past 12 months?

35) ASK 36-38 AS APPROPRIATE FOR EACH DECEASED PERSON. IF THERE ARE MORE THAN THREE DECEASED PEOPLE, USE ADDITIONAL FORM(S).

36) What are the names of the member(s) of your household died during the past 12 months?

37) Was (NAME) a man or a woman?

38) How old was (NAME) at the time of death?

RECORD AGE IN DAYS IF FEWER THAN 30 DAYS.

RECORD AGE IN COMPLETED YEARS IF 24 MONTHS (2 YEARS) OR MORE.

RECORD '95' IF 95 YEARS OR MORE.

HOUSEHOLD CHARACTERISTICS

101) Where does the water your household uses for drinking mainly come from?

102) Where does the water that the members of your household use for other things such as cooking or hand washing mainly come from?

103) Where is this supply source located?

104) How much time is needed to go there, get drinking water, and come back?

104A) How many kilometers away is this drinking water supply?

105) Who normally goes to the water supply to get drinking water?

RECORD '00' IF THIS PERSON IS NOT A MEMBER OF THE HOUSEHOLD.

105A) Among those cited, who most frequently goes to the water supply for drinking water?

106) Do you do anything to make the water safer to drink?

107) What do you usually do to make it safer?

Anything else?

RECORD ALL MENTIONED.

108) What kind of toilet do the majority of the members of your household use?

109) Do you share this installation with other households?

110) How many households, in all (including yours) use these toilets?

111) In your household do you have:

Electricity?
A radio?
A television?
A mobile telephone?
A landline telephone?
A refrigerator?
A stove?
Gas heating?
Air conditioning?
A fan?
A CD/DVD player?
A computer?
A grain mill?
A mixer?
An internet connection?
Cable or satellite television?
An electricity generator?
A water pump?

112) What kind of fuel does your household mainly use for cooking?

113) In this household, do you cook on an open flame, open oven, or closed oven?

114) Does the fire/oven have a chimney, hood, or neither?

115)Is the cooking normally done in the house, in a separate building, or outside?

116) Do you have a separate area you use for cooking?

117) PRINCIPLE FLOORING MATERIAL.

(WRITE DOWN OBSERVATION)

118) MAIN MATERIAL OF ROOF.

(WRITE DOWN OBSERVATION)

119) MAIN MATERIAL OF EXTERIOR WALLS

RECORD OBSERVATION

120) How many rooms in this household do you use for sleeping?

121) Does any member of this household own:

A watch/clock?
A bicycle?
A motorcycle or scooter?
An animal-drawn cart?
A car or truck?
A boat with a motor?

122) Does anyone in your household own any agricultural land?

123) How many hectares of agricultural land do members of this household own?

IF LESS THAN A HECTARE, RECORD '00'.

124) Does this household own any livestock, herds, other farm animals, or poultry?

125) How many of the following does this household own?

IF NONE, ENTER '00'.

IF 95 OR MORE, ENTER '95'.

IF UNKNOWN ENTER '98'.

Cattle?
Cows/Bulls?
Horses/donkeys/mules?
Goats?
Sheep?
Pigs?
Fowl?

126) Does any member of this household have a bank account?

127) Are you or anyone else the proprietor of this dwelling or are you a renter?

128) Do you or anyone else in this household have a property title for this dwelling?

129) What kind of written document do you have for the ownership of this dwelling?

130) Do you have written documentation for the rental of this dwelling?

131) What kind of written document do you have for the rental of this dwelling?

IF YES: What type of document or agreement do you have for the rental of this dwelling?

132) Do you feel sure of not being kicked out of this dwelling?

133) Have you been kicked out of your house at any time in the last five years?

134) DWELLING SITUATED IN OR CLOSE TO:

OBSERVE AND CIRCLE ALL CODES THAT DESCRIBE THE LIVING SPACE.

135) CONDITION OF THE DWELLING.

OBSERVE AND CIRCLE ALL CODES THAT DESCRIBE THE LIVING SPACE.

136) ENVIRONMENT OF DWELLING.

OBSERVE AND CIRCLE ALL CODES THAT DESCRIBE THE LIVING SPACE.

137) ASK RESPONDENT FOR A SPOONFUL OF SALT TEST THE SALT TO CHECK THE PRESENCE OF IODINE.

RECORD THE PARTS PER MILLION

CHECK COVER PAGE:

MOSQUITO PROTECTION

201) Do the windows in the dwelling's living spaces have screens or curtains to prevent mosquitos from entering?

202) ) Do the doors in the dwelling's living spaces have screens or curtains to prevent mosquitos from entering?

203) In the last twelve months, did someone come here to spray the interior walls to protect from mosquitos?

204) How long ago did this spraying occur?

205) Who sprayed the dwelling?

206) From the time the walls of your dwelling were sprayed, did you retouch them, for example, by putting mortar or paint on them, or put plaster on them or wash them?

207) Does your household have any mosquito nets that can be used while sleeping?

208) How many mosquito nets does your household have?

IF 7 OR MORE NETS, RECORD '7'.

209) Do you use the mosquito nets outside the bedrooms, for example in the yard, under the trees?

210) Does your family sleep under mosquito nets year-round?

211) Why don't your family members sleep under a mosquito net year-round?

212) Why are there no mosquito nets that can be used in your household?

CIRCLE ALL CODES MENTIONED.

213) ASK RESPONDENT TO SHOW YOU THE HOUSEHOLD'S MOSQUITO NETS.

IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

214) How many months has your household had this mosquito net?

IF LESS THAN A MONTH, RECORD '00'.

IF 3 YEARS OR MORE (36 MONTHS OR +) CIRCLE '95'.

215) How did you obtain this mosquito net?

216) OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.

217) When you got this mosquito net, was it already treated with an insecticide to kill or repel mosquitos?

218) Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitos?

219) How many months ago was the net last soaked or dipped?

IF LESS THAN ONE MONTH AGO, RECORD '00'.

220) Did anyone sleep under this mosquito net last night?

221) Who slept under this mosquito net last night?

RECORD THE PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

222) RETURN TO QUESTION 213 FOR THE FOLLOWING MOSQUITO NET OR, IF NO MORE NETS, GO TO 301.

CHILDREN 'S WORK (FOR CHILDREN 5-12 YEARS OLD)

(ONLY IN HOUSEHOLDS NOT SELECTED FOR THE MEN'S SURVEY AND HIV TEST)

301) CHECK COLUMNS (5) AND (7): NUMBER OF CHILDREN BETWEEN 5 AND 14 USUALLY LIVING IN THE HOUSEHOLD:

ASK THE FOLLOWING QUESTIONS OF THE PERSON RESPONSIBLE FOR EACH CHILD (IF MORE THAN 8 CHILDREN, USE ADDITIONAL QUESTIONNAIRE[S])

Now I would like to ask you some questions about the kind of work that children living her do.

302) RECORD THE LINE NUMBER OF EACH CHILD IN THE ORDER OF COLUMN 1 OF HOUSEHOLD SURVEY.

303) RECORD THE NAME OF EACH CHILD.

304) Since last (DAY OF WEEK DURING WHICH SURVEY ADMINISTERED), has (NAME) done any kind of work for someone not a member of this household?

IF 'YES': Was he/she paid in cash or kind for this work?

305) Since last (DAY OF WEEK DURING WHICH SURVEY ADMINISTERED), about how many hours has (NAME) done any kind of work for someone not a member of this household?

306) In the last 12 months, has (NAME) done any kind of work for someone not a member of this household?

IF 'YES': Was he/she paid in cash or kind for this work?

307) Since last (DAY OF WEEK DURING WHICH SURVEY ADMINISTERED), has (NAME) done any kind of work for a member of this household?

For example, done dishes, gone shopping, cleaned, laundered clothes, gotten water, or watched children?

308) Since last (DAY OF WEEK DURING WHICH SURVEY ADMINISTERED), about how many hours has (NAME) done housework?

309) Since last (DAY OF WEEK DURING WHICH SURVEY ADMINISTERED), has (NAME) done any other work for the family in the fields or in family business (farm, business, or street vending)?

310) Since last (DAY OF WEEK DURING WHICH SURVEY ADMINISTERED), about how many hours has (NAME) done any work for the family in the fields or in family business?

WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5 YEARS

401) CHECK COLUMN 11 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME OF EACH CHILD BETWEEN 0-5 YEARS. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S) THE FINAL WEIGHT AND HEIGHT MEASUREMENT MUST BE RECORDED IN 409.

402) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

403) IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF BIRTH FROM BIRTH HISTORY AND ASK THE DAY.

IF MOTHER NOT INTERVIEWED, ASK:
What is (NAME)'s date of birth?

405) CHECK 403:
CHILD BORN IN JANUARY 2005 OR LATER OR UNDER 60 MONTHS?

406) WEIGHT IN KILOGRAMS:

407) HEIGHT IN CENTIMETERS:

408) MEASURED LYING DOWN OR STANDING UP?

409) RESULT HEIGHT AND WEIGHT MEASURES

410) CHECK 403:
IS CHILD AGE 0-5 MONTHS , I.E.. WAS CHILD BORN IN MONTH OF INTERVIEW OR 5 PREVIOUS MONTHS?

411) LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD
(COLUMN 1), RECORD '00' IF NOT LISTED.

412) READ CONSENT STATEMENT FOR ANEMIA TEST TO THE PARENT/ ADULT RESPONSIBLE FOR THE CHILD. CIRCLE THE APPROPRIATE CODE AND SIGN.

413) READ CONSENT STATEMENT FOR MALARIA TO THE PARENT/ ADULT RESPONSIBLE FOR THE CHILD. CIRCLE THE APPROPRIATE CODE AND SIGN.

414) CHECK 412-413 AND PREPARE THE NECESSARY INSTRUMENTS FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED. THEN , PERFORM THE TESTS. FOR EACH ELIGIBLE CHILD, THE RESULT OF THE ANEMIA TEST MUST BE RECORDED IN 415 AND IN 417 FOR MALARIA, EVEN IF CONSENT WAS NOT GIVEN, CHILD WAS NOT PRESENT, OR COULD NOT BE TESTED FOR OTHER REASONS.

415) RESULT CODE FOR ANEMIA TEST

416) NOTE HEMOGLOBIN LEVEL HERE IN THE ANEMIA PAMPHLET

417) RESULT CODE FOR MALARIA TEST

418) RESULT OF MALARIA TEST

419) READ THE INFORMATION FOR MALARIA TREATMENT AND THE CONSENT STATEMENT TO THE PARENT OR OTHER ADULT RESPONSIBLE FOR THE CHILD. CIRCLE THE APPROPRIATE CODE AND SIGN.

420) RETURN TO 403 IN THE NEXT COLUMN OR THE FIRST COLUMN OF NEXT QUESTIONNAIRE. IF NO OTHER CHILD, GO TO 501.
CONSENT DECLARATION FOR CHILD ANEMIA TEST.

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.

We ask that all children born in 2005 or later take part in anemia testing in this survey and give a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the anemia test?

CONSENT DECLARATION FOR CHILD MALARIA TEST

As part of this survey, we are asking people all over the country to take a malaria test. Malaria is a serious health problem caused by a parasite transmitted by mosquito bites. This survey will assist the government to develop programs to prevent and treat malaria.

We ask that all children born in 2005 or later take part in anemia testing in this survey and give a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the malaria test?

TREATMENT FOR CHILDREN WITH A POSITIVE MALARIAL PARASITE TEST

IF THE MALARIAL PARASITE TEST IS POSITIVE:

The diagnostic test for malaria shows that your child has malaria.

We can give free medication. These medications are called ANTIMALARIAL COMBINATION THERAPY (ACT). ACT is very effective and will in a few days eliminate the fever and other symptoms. ACT is also very safe. However, as with every medication, there are side effects, and this medication can have them.

The most common side effects are vertigo, fatigue, loss of appetite, and palpitations. The combination treatment should never be taken by persons with a serious heart condition or a serious case of malaria (for example Cerebral) or problems regulating salt levels in the body

ASK IF CHILD SUFFERS FROM ONE OF THESE PROBLEMS, TO THE MOTHER'S KNOWLEDGE IF SO, THE ACT MUST NOT BE GIVEN. EXPLAIN THE RISKS OF MALARIA, AND REFER THE CHILD TO THE NEAREST HEALTH FACILITY.

You do not have to give the child the medication. It is for you to decide. Please tell me if you accept the medication or not.

ACT TREATMENT (Artesumate and Amodiquine)
Approximate weight (KG)
Fewer than 9 kgs (less than a year)
Between 9- 18kgs (1-5 years)

DOSAGE
DAY 1 (once a day) 1 pill (Artesunate 25mg + Amodiaquine 67.5 mg)
DAY 1 (once a day) 1 pill (Artesunate 50mg + Amodiaquine 135 mg)

DAY 2 (once a day) 1 pill (Artesunate 25mg + Amodiaquine 67.5 mg)
DAY 2 (once a day) 1 pill (Artesunate 50mg + Amodiaquine 135 mg)

DAY 3 (once a day) 1 pill (Artesunate 25mg + Amodiaquine 67.5 mg)
DAY 3 (once a day) 1 pill (Artesunate 50mg + Amodiaquine 135 mg)

MUST ALSO BE SAID TO MOTHER/ ADULT RESPONSIBLE FOR THE CHILD:

If (NAME OF CHILD) has one of the following symptoms, you must take him or her immediately to a health professional to receive care:

- High fever
- Convulsions, coma
- Rapid breathing or difficulty breathing
- Unable to drink or nurse
- Becomes sicker or does not improve after 2 days

WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENT FOR WOMEN AGE 15-49 YEARS

501) CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME OF EACH WOMAN BETWEEN 15 AND 49 YEARS OLD.

IF MORE THAN 3 WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

THE FINAL WEIGHT AND HEIGHT MEASUREMENT MUST BE RECORDED IN 505 AND IN 512 FOR THE RESULT OF THE ANEMIA TEST.

502) LINE NUMBER FROM COLUMN 9.
NAME FROM COLUMN 2.

503) WEIGHT IN KILOGRAMS.

504) HEIGHT IN CENTIMETERS.

505) RESULT HEIGHT AND WEIGHT MEASURES.

505A) AGE: CHECK COLUMN 7.

506) MARITAL STATUS: CHECK COLUMN 8.

507) RECORD THE LINE NUMBER OF THE PARENT/OTHER ADULT RESPONSIBLE FOR THE ADOLESCENTS.

RECORD '00' IF PERSON NOT LISTED.

508) READ CONSENT STATEMENT FOR ANEMIA TEST. FOR THE NEVER IN A UNION WOMEN BETWEEN 15-17, ASK FOR THE CONSENT OF TO THE PARENT/ OTHER RESPONSIBLE ADULT BEFORE ASKING FOR THE CONSENT OF THE RESPONDENT.

CONSENT DECLARATION FOR ANEMIA TEST

READ THE CONSENT STATEMENT TO EACH RESPONDENT. RECORD CODE '1' IN 508 IF RESPONDENT ACCEPTS THE ANEMIA TEST AND CODE '3' IF SHE REFUSES.

FOR WOMEN BETWEEN 15 AND 17 NEVER IN A UNION, ASK FOR THE CONSENT OF THE PARENT/ ADULT IDENTIFIED IN 507 BEFORE ASKING FOR THE CONSENT OF THE ADOLESCENTS HERSELF. CIRCLE CODE '2' IN 508 IF THE PARENTS REFUSE. ONLY PERFORM THE TEST IF BOTH CONSENTS, THAT OF THE PARENT/ADULT AND THE ADOLESCENT RESPONDENT, HAVE BEEN RECEIVED.

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.

For this survey, we need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

The blood will be tested for anemia immediately, and the result told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

Do you have any questions?

You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to participate in the anemia test?
Do you agree to participate in the anemia test?

LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

509) CHECK QUESTION 226 FROM WOMEN'S QUESTIONNAIRE.

Are you pregnant?

510) CHECK 508 AND PREPARE THE NECESSARY INSTRUMENTS FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED. THEN, PERFORM THE TESTS. FOR EACH ELIGIBLE WOMAN, THE RESULT OF THE ANEMIA TEST MUST BE RECORDED IN 512. EVEN IF CONSENT WAS NOT GIVEN, RESPONDENT WAS NOT PRESENT, OR COULD NOT BE TESTED FOR OTHER REASONS.

511) NOTE HEMOGLOBIN HERE AND ON THE BROCHURE ON ANEMIA.

512) RESULT CODE FOR ANEMIA TEST.

513) RETURN TO QUESTION 503 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT QUESTIONNAIRE. IF NO MORE WOMEN, GO TO 514.

514) WOMEN'S SELECTION TABLE FOR "HOUSEHOLD RELATIONS" (ONLY FOR THE HOUSEHOLDS NOT SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST)

THE SECTION ON "HOUSEHOLD RELATIONS" IN THE WOMEN'S INDIVIDUAL QUESTIONNAIRE APPLIES TO WOMEN IN HOUSEHOLDS FOR WHICH THERE IS NEITHER A MEN'S SURVEY NOR AN HIV TEST.
HOWEVER, ONLY A SINGLE WOMAN PER HOUSEHOLD WILL BE SURVEYED IN THIS SECTION. THE BELOW TABLE ALLOWS YOU TO SELECT THIS WOMAN AT RANDOM.

1 - THERE IS ONLY ONE ELIGIBLE WOMAN IN THE HOUSEHOLD
This woman will be selected for the "HOUSEHOLD RELATIONS" section of the women's questionnaire

2 - THERE ARE MORE THAN ONE ELIGIBLE WOMEN IN THE HOUSEHOLD

a) take the last digit of the structure number recorded on the questionnaire cover page
b) this is the line number digit to be selected
c) check the total number of eligible women in column 9 in the Household Table.
d) this number is that of the column to be selected.
e) find the box that corresponds to the intersection of the line of the intersecting columns and circle this number.
f) this number corresponds to the woman who will be selected for the "HOUSEHOLD RELATIONS" section: the 1st, 2nd,3rd, etc.
g) In column 9 of the household table, circle the line number of the woman.

Example:
The household structure number is 136: select line 6.
There are 3 eligible women in the household, select column 3.
The box at the intersection of line 6 and column 3 is 2: the 2nd eligible woman listed in the household table will be selected.
If the line number of these 3 eligible women is : '02', '04' and '07', the woman selected is the second woman listed, so, that of the line number '04'.

Last digit of structure number:
0
1
2
3
4
5
6
7
8
9

Total number of eligible women:
1 2 3 4 5 6 7 8 9 10+
1 2 2 3 5 5 3 6 8 9
1 1 3 4 1 6 4 1 6 4 7 9 10
1 2 1 1 2 1 5 8 1 1
1 1 2 2 3 2 6 1 2 2
1 2 3 3 4 3 7 2 3 3
1 1 1 4 5 4 1 3 4 4
1 2 2 1 1 5 2 4 5 5
1 1 3 2 2 6 3 5 6 6
1 2 1 3 3 1 4 6 7 7
1 1 2 4 4 2 4 5 7 8 8

NAME OF WOMAN SELECTED: ___

LINE NUMBER OF THE WOMAN SELECTED IN THE HOUSEHOLD TABLE: ___

THIS HOUSEHOLD NOT SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST (END)

HANDICAP (ONLY FOR HOUSEHOLDS SELECTED FOR MEN'S SURVEY AND HIV TEST)

601) Now I would like to ask some questions about the health of each person usually living in your household, including small children.

Is there anyone in your household who is missing a limb, for example, a hand, an arm, a foot, or a leg?

IF YES: Can you give me the names of these people?

RECORD THE NAME AND LINE NUMBER OF EACH PERSON WHO IS MISSING A LIMB. ASK 603 ABOUT THE 1ST PERSON, THEN THE 2ND PERSON, ETC.

(IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

602) NAME AND LINE NUMBER FROM COLUMN 2 AND COLUMN 1 FROM HOUSEHOLD SCHEDULE.

603) Has (NAME) had this problem since birth, or is it due to an accident, an illness, or another cause?

604) Is there anyone in your household with a deformity of an upper or lower extremity and who cannot walk or has difficulty walking and/or using his/her arms or hands?

IF YES: Could you tell me the names of these people?

RECORD THE NAME AND LINE NUMBER OF EACH PERSON WITH A DEFORMITY. ASK 606 AND 607 FOR THE 1ST PERSON, THEN THE 2ND PERSON, ETC.

(IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

605) NAME AND LINE NUMBER FROM COLUMN 2 AND COLUMN 1 FROM HOUSEHOLD SCHEDULE.

606) Has (NAME) had this deformity from birth or was it caused by an accident, and illness, or another cause?

607) Does (NAME) only have difficulty using his/her arms or legs, or can (NAME) not use his/her arms or legs at all?

608) Is anyone in your household blind or nearly blind?

IF YES: Can you tell me the name of these people?

RECORD THE NAME AND LINE NUMBER OF EACH PERSON WITH VISION PROBLEMS. ASK 610 AND 611 OF THE 1ST PERSON, THEN THE 2ND, ETC.

(IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

609) NAME AND LINE NUMBER FROM COLUMN 2 AND COLUMN 1 FROM HOUSEHOLD SCHEDULE.

610) Has (NAME) had vision problems since birth, or were the problems caused by an accident, an illness, or another cause?

611) Does (NAME) have trouble seeing or is (NAME) completely blind?

612) Is there anyone in your household who is almost or completely deaf?

IF YES: Can you tell me the names of these people?

RECORD THE NAME AND LINE NUMBER OF EACH PERSON WITH HEARING PROBLEMS. ASK 614 AND 615 OF THE 1ST PERSON, THEN THE 2ND PERSON, ETC.

(IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

613) NAME AND LINE NUMBER FROM COLUMN 2 AND COLUMN 1 FROM HOUSEHOLD SCHEDULE.

614) Did (NAME) have hearing problems since birth or were they caused by an accident, an illness, or another cause?

615) Does (NAME) have difficulty hearing or is (NAME) completely deaf?

616) Is there anyone in your household that has serious difficulty talking or is mute?

IF YES: Can you tell me the names of these people?

RECORD THE NAME AND NUMBER OF EACH PERSON WITH SPEECH PROBLEMS. ASK 618 AND 619 FOR THE FIRST PERSON, THEN THE 2ND, ETC.

(IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

617) NAME AND LINE NUMBER FROM COLUMN 2 AND COLUMN 1 FROM HOUSEHOLD SCHEDULE.

618) Has (NAME) had these problems with talking since birth or were they caused by an accident, an illness, or another cause?

619) Does (NAME) have difficulty speaking or is (NAME) completely mute?

620) Is there anyone in your household who is missing certain bodily extremities, such as finger tips, toes, nose, or ears?

IF YES: Can you tell me the names of these people?

RECORD NAME AND LINE NUMBER OF EACH PERSON WHO IS MISSING CERTAIN BODY PARTS. ASK 622 AND 623 FOR THE 1ST PERSON, THEN THE 2ND, ETC.

(IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

621) NAME AND LINE NUMBER FROM COLUMN 2 AND COLUMN 1 FROM HOUSEHOLD SCHEDULE.

622) Has (NAME) had this problem since birth or was it caused by an accident, an illness, or another cause?

623) Does name have certain extremities that have no feeling?

624) Does anyone in your household have behavioral problems?

IF YES: Can you tell me the names of these people?

RECORD NAME AND LINE NUMBER OF EACH PERSON WITH BEHAVIORAL PROBLEMS. ASK 626 AND 627 FOR THE 1ST PERSON, THEN THE 2ND, ETC.

(IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

625) NAME AND LINE NUMBER FROM COLUMN 2 AND COLUMN 1 FROM HOUSEHOLD SCHEDULE.

626) Has (NAME) had this problem since birth or was it caused by an accident, and illness, or another cause?

627) Are (NAME)'s problems mild or serious?

HOUSEHOLD HEALTH EXPENSES (ONLY FOR HOUSEHOLDS SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST)

701) Is a member of your household currently ill, or suffering from a long term illness or injury, or was ill in the last 30 days?

702) How many members of your household are currently sick, or suffering from a long term illness or injury, or were ill in the last 30 days?

703) Now I'd like to ask you some questions about each person who was ill or injured at one point or another in the last 30 days. Can you tell me each person's name?
Then we will talk in detail about each one, one after another.

RECORD IN 704 THE NAME AND LINE NUMBER OF EACH SICK PERSON, THEN ASK ALL THE RELEVANT QUESTIONS FOR EACH PERSON. FINISH ASKING ALL THE QUESTIONS ABOUT THE FIRST SICK PERSON BEFORE MOVING ON TO THE 2ND, ETC.

(IF THERE ARE MORE THAN 3 SICK PEOPLE, USE THE ADDITIONAL QUESTIONNAIRE.)

704) NAME AND LINE NUMBER COLUMN 2 AND COLUMN 1 FROM HOUSEHOLD SCHEDULE

705) In your opinion, was (NAME)'s illness serious, moderate, or mild?

706) Did they use self-treatment?

707) From whom did they seek drugs for the self-treatment?

708) What was the total sum of the drug purchases for (NAME)'s self-treatment?

AMOUNT IN FCFA.

709) After the self-treatment, did you seek advice or other care to treat (NAME)'s illness or injury?

710) Did you seek advice or other care to treat (NAME)'s illness or injury?

711) From whom did they seek advice or treatment for (NAME)'s illness/injury?

IF "HOSPITAL" OR "HEALTH CENTER", CHECK THE NAME AND TYPE AND CIRCLE THE APPROPRIATE CODE.

IF "DOCTOR" OR "NURSE", CHECK TO SEE IF THE SICK PERSON WENT TO THE INDIVIDUAL OR IF THE "DOCTOR"/ "NURSE" WENT TO THE SICK PERSON'S DWELLING. CIRCLE THE APPROPRIATE CODE.

712) What was the total sum of the expenses for transportation to go to and return from (LOCATION OF CARE IN 711)?

AMOUNT IN FCFA.

713) What was the total sum of the expenses for the consultation and care at (LOCATION OF CARE IN 711)?

AMOUNT IN FCFA.

714) What was the total sum of expenses for drugs, exams, and other products prescribed at (LOCATION OF CARE IN 711)?

AMOUNT IN FCFA.

715) Was (NAME) admitted to the hospital for at least one night to treat his/her illness/injury?

716) What was the total sum of expenses for this hospitalization?

AMOUNT IN FCFA.

717) What was the total sum of expenses for transportation to this hospitalization?

AMOUNT IN FCFA.

718) After the first visit to (LOCATION OF CARE FROM 711), was there a second consultation at the same place or were there other visits to seek care to treat (NAME)'s illness/injury elsewhere?

719) For this second visit, from whom did you seek advice or treatment to treat (NAME)'s illness/injury?

720) What was the total sum of the expenses for transportation to go to and return from (LOCATION OF CARE IN 711)?

AMOUNT IN FCFA.

721) What was the total sum of expenses for the consultation and care from (LOCATION OF CARE FROM 719)?

AMOUNT IN FCFA.

722) What was the total sum of expenses for the drugs, exams, and other products prescribed at (LOCATION OF CARE FROM 719)?

AMOUNT IN FCFA.

723) Was (NAME) admitted to the hospital for at least one night to treat his/her illness/injury?

724) What was the total sum of expenses for this hospitalization?

AMOUNT IN FCFA.

725) What was the total sum of expenses for transportation to this hospitalization?

AMOUNT IN FCFA.

726) Check 708, 712, 713, 714, 716, 717, 720, 721, 722, 724 and 725:

727) Who paid the expenses for the care and treatment of (NAME)'s illness/injury?

RECORD THE NAME AND LINE NUMBER OF THE PERSON(S) WHO PAID.
ENTER '00' IF THE PERSON DOES NOT LIVE IN THE HOUSEHOLD.

728) Where did (NAME (1) FROM 727) get the money to pay for the expenses incurred for the care and treatment of (NAME)'s illness/injury?

Where did (NAME (2) FROM 727) get the money to pay for the expenses incurred for the care and treatment of (NAME)'s illness/injury?

Where did (NAME (3) FROM 727) get the money to pay for the expenses incurred for the care and treatment of (NAME)'s illness/injury?

729) GO BACK TO 705 IN NEXT COLUMN; OR, IF NO MORE SICK PEOPLE, GO TO 801.

HIV TEST FOR WOMEN BETWEEN 15 AND 49 YEARS OLD (ONLY IN HOUSEHOLDS SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST)

801) CHECK COLUMN 9 IN HOUSEHOLD TABLE. RECORD THE LINE NUMBER AND THE NAME OF ALL WOMEN BETWEEN 15 AND 49 IN QUESTION 802.
IF THERE ARE MORE THAN 3 WOMEN, USE ADDITIONAL QUESTIONNAIRE(S)
THE FINAL RESULT OF THE BLOOD TEST FOR HIV MUST BE RECORDED IN 809

802) LINE NUMBER FROM COLUMN 9.
NAME FROM COLUMN 2.

803) AGE: CHECK COLUMN 7.

804) MARITAL STATUS: CHECK COLUMN 8.

805) RECORD THE LINE NUMBER OF THE PARENT/OTHER ADULT RESPONSIBLE FOR THE ADOLESCENTS.

RECORD '00' IF PERSON NOT LISTED.

806) READ CONSENT STATEMENT FOR HIV TEST. FOR THE NEVER IN A UNION WOMEN BETWEEN 15-17, ASK FOR THE CONSENT OF TO THE PARENT/ OTHER RESPONSIBLE ADULT BEFORE ASKING FOR THE CONSENT OF THE RESPONDENT.

807) CHECK 806 AND PREPARE THE NECESSARY INSTRUMENTS AND DRAW THE BLOOD. FOR EACH ELIGIBLE WOMAN, THE CODE FOR THE RESULT MUST BE RECORDED IN 809, EVEN IF CONSENT WAS NOT GIVEN, RESPONDENT WAS NOT PRESENT, OR COULD NOT BE TESTED FOR OTHER REASONS.

808) BAR CODE LABEL.

PUT THE FIRST BAR CODE HERE

PUT THE SECOND BAR CODE ON THE RESPONDENT'S FILTER PAPER AND THE THIRD ON THE TRANSMITTAL FORM.

809) RESULT OF THE HIV TEST.

CONSENT DECLARATION FOR HIV TEST

READ THE CONSENT STATEMENT TO EACH RESPONDENT. RECORD CODE '1' IN 806 IF RESPONDENT ACCEPTS THE HIV TEST AND CODE '3' IF SHE REFUSES.
FOR WOMEN BETWEEN 15 AND 17NEVER IN A UNION, ASK FOR THE CONSENT OF THE PARENT/ ADULT IDENTIFIED IN 805 BEFORE ASKING FOR THE CONSENT OF THE ADOLESCENT HERSELF. CIRCLE CODE '2' IN 806 IF THE PARENTS REFUSE. ONLY PERFORM THE TEST IF BOTH CONSENTS, THAT OF THE PARENT/ADULT AND THE ADOLESCENT RESPONDENT, HAVE BEEN RECEIVED.

As part of this survey, we are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious health problem. This test will assist the government to measure the severity of the problem of AIDS in Cameroun.

For this test, we need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

No name will be attached to the blood samples and we will not be able to tell you the results. No one else will be able to know (NAME OF ADOLESCENT) results either. If you would like to know if you have HIV, I can give you a list of the (closest) facilities that offer tests and counseling for HIV. I would also give you a coupon for free services in these facilities for you (and for your partner if you would like).

Do you have any questions?

You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to participate in the HIV test?
Do you agree to participate in the HIV test?

LINE NUMBER FROM COLUMN 9.
NAME FROM COLUMN 2.

810) CHECK 809: PARTICIPATION IN HIV TEST.

811) READ CONSENT STATEMENT FOR ADDITIONAL TESTS. FOR THE NEVER IN A UNION WOMEN BETWEEN 15-17, ASK FOR THE CONSENT OF TO THE PARENT/ OTHER RESPONSIBLE ADULT IDENTIFIED IN 805 BEFORE ASKING FOR THE CONSENT OF THE RESPONDENT.

812) ADDITIONAL TESTS:

CHECK 811:
IF CONSENT NOT GIVEN, WRITE: 'NO OTHER TESTS' ON THE FILTER PAPER.

813) RETURN TO 803 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE OR THE FIRST COLUMN OF NEW QUESTIONNAIRE. IF NO OTHER WOMEN, GO TO 814.

CONSENT DECLARATION FOR ADDITIONAL TESTS

READ THE CONSENT STATEMENT TO EACH RESPONDENT. RECORD CODE '1' IN 811 IF RESPONDENT ACCEPTS THE TESTS AND CODE '3' IF SHE REFUSES.
FOR WOMEN BETWEEN 15 AND 17NEVER IN A UNION, ASK FOR THE CONSENT OF THE PARENT/ ADULT IDENTIFIED IN 805 BEFORE ASKING FOR THE CONSENT OF THE ADOLESCENT HERSELF. CIRCLE CODE '2' IN 811 IF THE PARENTS REFUSE. ONLY PERFORM THE TEST IF BOTH CONSENTS, THAT OF THE PARENT/ADULT AND THE ADOLESCENT RESPONDENT, HAVE BEEN RECEIVED.

We ask you to authorize the Pasteur Center of Cameroon to retain a part of the blood sample in the laboratory to be used in future tests or research. We do not know exactly what tests will be performed.

No name or other identifying information will be attached to the blood samples. You are not obligated to accept.

If you do not want the blood sample to be retained, you can still participate in this survey's HIV test (you can still authorize [NAME OF ADOLESCENT] to participate in this survey's HIV test).

Do you agree to allow us to retain the blood sample for future tests or research?

HIV TEST FOR MEN BETWEEN 15 AND 49 YEARS OLD (ONLY IN HOUSEHOLDS SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST)

814) CHECK COLUMN 10 IN HOUSEHOLD TABLE. RECORD THE LINE NUMBER AND THE NAME OF ALL MEN BETWEEN 15 AND 49 IN QUESTION 815.
IF THERE ARE MORE THAN 3 MEN, USE ADDITIONAL QUESTIONNAIRE(S)
THE FINAL RESULT OF THE BLOOD TEST FOR HIV MUST BE RECORDED IN 822

815) LINE NUMBER COLUMN 10.
NAME COLUMN 2.

816) AGE: CHECK COLUMN 7.

817) MARITAL STATUS: CHECK COLUMN 8

818) RECORD THE LINE NUMBER OF THE PARENT/OTHER ADULT RESPONSIBLE FOR THE ADOLESCENT.

RECORD '00' IF PERSON NOT LISTED.

819) READ CONSENT STATEMENT FOR HIV TESTS FOR THE NEVER IN A UNION WOMEN BETWEEN 15-17, ASK FOR THE CONSENT OF TO THE PARENT/ OTHER RESPONSIBLE ADULT LISTED IN 818 BEFORE ASKING FOR THE CONSENT OF THE RESPONDENT.

820) CHECK 806 AND PREPARE THE NECESSARY INSTRUMENTS AND DRAW THE BLOOD. FOR EACH ELIGIBLE MAN, THE CODE FOR THE RESULT MUST BE RECORDED IN 809, EVEN IF CONSENT WAS NOT GIVEN, RESPONDENT WAS NOT PRESENT, OR COULD NOT BE TESTED FOR OTHER REASONS.

821) BAR CODE LABEL.

PUT THE FIRST BAR CODE HERE.

PUT THE SECOND BAR CODE ON THE RESPONDENT'S FILTER PAPER AND THE THIRD ON THE TRANSMITTAL FORM.

822) RESULT OF THE HIV TEST.

CONSENT DECLARATION FOR HIV TEST

READ THE CONSENT STATEMENT TO EACH RESPONDENT. RECORD CODE '1' IN 819 IF RESPONDENT ACCEPTS THE HIV TEST AND CODE '3' IF HE REFUSES.
FOR MEN BETWEEN 15 AND 17 NEVER IN A UNION, ASK FOR THE CONSENT OF THE PARENT/ ADULT IDENTIFIED IN 818 BEFORE ASKING FOR THE CONSENT OF THE ADOLESCENT HERSELF. CIRCLE CODE '2' IN 819 IF THE PARENTS REFUSE. ONLY PERFORM THE TEST IF BOTH CONSENTS, THAT OF THE PARENT/ADULT AND THE ADOLESCENT RESPONDENT, HAVE BEEN RECEIVED.

As part of this survey, we are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious health problem. This test will assist the government to measure the severity of the problem of AIDS in Cameroun.

For this test, we need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

No name will be attached to the blood samples and we will not be able to tell you the results. No one else will be able to know (NAME OF ADOLESCENT) results either. If you would like to know if you have HIV, I can give you a list of the (closest) facilities that offer tests and counseling for HIV. I would also give you a coupon for free services in these facilities for you (and for your partner if you would like).

Do you have any questions?

You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to participate in the HIV test?

Do you agree to participate in the HIV test?

LINE NUMBER FROM COLUMN 10.
NAME FROM COLUMN 2.

823) CHECK 822: PARTICIPATION IN HIV TEST.

824) READ CONSENT STATEMENT FOR ADDITIONAL TESTS. FOR THE NEVER IN A UNION WOMEN BETWEEN 15-17, ASK FOR THE CONSENT OF TO THE PARENT/ OTHER RESPONSIBLE ADULT IDENTIFIED IN 805 BEFORE ASKING FOR THE CONSENT OF THE RESPONDENT.

825) ADDITIONAL TESTS:

CHECK 824:
IF CONSENT NOT GIVEN, WRITE: 'NO OTHER TESTS' ON THE FILTER PAPER.

826) RETURN TO 816 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE OR THE FIRST COLUMN OF NEW QUESTIONNAIRE. IF NO OTHER WOMEN, GO TO 901.

CONSENT DECLARATION FOR ADDITIONAL TESTS

READ THE CONSENT STATEMENT TO EACH RESPONDENT. RECORD CODE '1' IN 811 IF RESPONDENT ACCEPTS THE TESTS AND CODE '3' IF HE REFUSES.
FOR MEN BETWEEN 15 AND 17 NEVER IN A UNION, ASK FOR THE CONSENT OF THE PARENT/ ADULT IDENTIFIED IN 818 BEFORE ASKING FOR THE CONSENT OF THE ADOLESCENT HERSELF. CIRCLE CODE '2' IN 824 IF THE PARENTS REFUSE. ONLY PERFORM THE TEST IF BOTH CONSENTS, THAT OF THE PARENT/ADULT AND THE ADOLESCENT RESPONDENT, HAVE BEEN RECEIVED.

We ask you to authorize the Pasteur Center of Cameroon to retain a part of the blood sample in the laboratory to be used in future tests or research. We do not know exactly what tests will be performed.

No name or other identifying information will be attached to the blood samples. You are not obligated to accept.

If you do not want the blood sample to be retained, you can still participate in this survey's HIV test (you can still authorize [NAME OF ADOLESCENT] to participate in this survey's HIV test).

Do you agree to allow us to retain the blood sample for future tests or research?

901) MEN'S SELECTION TABLE FOR "HOUSEHOLD RELATIONS" (ONLY FOR THE HOUSEHOLDS NOT SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST)

THE SECTION ON "HOUSEHOLD RELATIONS" IN THE MEN'S INDIVIDUAL QUESTIONNAIRE APPLIES TO WOMEN IN HOUSEHOLDS FOR WHICH THERE IS NEITHER A MEN'S SURVEY NOR AN HIV TEST.

HOWEVER, ONLY A SINGLE MAN PER HOUSEHOLD WILL BE SURVEYED IN THIS SECTION. THE BELOW TABLE ALLOWS YOU TO SELECT THIS MAN AT RANDOM.

1- THERE IS ONLY ONE ELIGIBLE MAN IN THE HOUSEHOLD
This man will be selected for the "HOUSEHOLD RELATIONS" section of the men's questionnaire

2- THERE ARE MORE THAN ONE ELIGIBLE MEN IN THE HOUSEHOLD

a) take the last digit of the structure number recorded on the questionnaire cover page
b) this digit is the row number to be selected
c) check the total number of eligible men in column 9 in the Household Table.
d) this number is that of the column to be selected.
e) find the box that corresponds to the intersection of the line of the intersecting columns and circle this number.
f) this number corresponds to the woman who will be selected for the "HOUSEHOLD RELATIONS" section: the 1st, 2nd, 3rd, etc.
g) In column 10 of the household table, circle the line number of the man.

Example:
The household structure number is 136: select line 6.
There are 3 eligible men in the household, select column 3.
The box at the intersection of line 6 and column 3 is 2: the 2nd eligible man listed in the household table will be selected.
If the line number of these 3 eligible women is : '02', '04' and '07', the man selected is the second woman listed, so, that of the line number '04'.

Last digit of structure number:
0
1
2
3
4
5
6
7
8
9

Total number of eligible men:
1 2 3 4 5 6 7 8 9 10+
1 2 2 3 5 5 3 6 8 9
1 1 3 4 1 6 4 1 6 4 7 9 10
1 2 1 1 2 1 5 8 1 1
1 1 2 2 3 2 6 1 2 2
1 2 3 3 4 3 7 2 3 3
1 1 1 4 5 4 1 3 4 4
1 2 2 1 1 5 2 4 5 5
1 1 3 2 2 6 3 5 6 6
1 2 1 3 3 1 4 6 7 7
1 1 2 4 4 2 4 5 7 8 8

NAME OF MAN SELECTED: ___

LINE NUMBER OF THE MAN SELECTED IN THE HOUSEHOLD TABLE: ___

THIS HOUSEHOLD NOT SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST (END)